Hoarding: A Growing Concern

 Dr. Landau reports increasing calls reporting Persons of Concern exhibiting hoarding behaviors. She has summarized the following research from Dr. Stephen Soreff to help you and loved ones identify problematic behaviors and how to get help. 


Hoarding disorder is a difficulty discarding possessions. Clinically significant hoarding has an estimated prevalence of 2-6% in the United States and Europe.

Hoarding disorder is a persistent difficulty in discarding or parting with possessions, regardless of their actual value. Many healthy individuals collect material goods, such as stamps and porcelain figurines; others have difficulty parting with objects due to their sentimental or material value. Hoarding disorder occurs when individuals accumulate to such an extent that it affects their ability to use the living areas of their homes, causes distress, places them in danger, or restricts their quality of life. Clinically significant hoarding is estimated to have a prevalence of 2%-6% of the population in the United States and Europe.


Hoarding may not be limited to inanimate objects.

Hoarding may be divided into two subcategories: object hoarding and animal hoarding. The most prominent difference between object hoarding and animal hoarding is the extent of unsanitary conditions and the poorer insight characteristic of animal hoarders. Lacking insight into their behavior and its consequences, they frequently do not comprehend that they are not adequately providing for the animals and are placing them in harm's way. Most individuals who hoard animals also hoard inanimate objects.

Hoarders rarely recognize their condition and may only be prodded into seeking help by concerned family and friends. Clinical clues regarding the presence of hoarding disorder include cellulitis or skin infections due to living in squalid conditions. Patients may also have fractures due to falls caused by tripping over accumulated objects. The course of hoarding tends to be chronic and progressive, with symptoms starting in the teens and severity increasing with age. Hence, the amount of hoarded material may greatly increase over time.


Hoarding disorder has a significantly greater prevalence among males than among females.

The cause of hoarding disorder is unknown. Although many patients report a family history of hoarding, genetic studies have pointed toward several different genes. Numerous psychological theories concerning the etiology of hoarding disorder point to characteristics often displayed by hoarders, including difficulty initiating and completing tasks, excessive sentimental attachment to possessions, indecisiveness, and impaired memory confidence. In late-onset hoarding, traumatic life events may act as precipitants.


Hoarding disorder is best assessed by Conducting a home visit or viewing photos of the main living areas.

Congested and cluttered living areas are a diagnostic criterion for hoarding disorder, and conducting a home visit and viewing photos of the main living areas are frequently the best ways to assess hoarding disorder. It may also be helpful to speak to friends and family members because hoarders often lack insight into their disorder and frequently do not view their condition as harmful or abnormal. Visits to the residence demonstrate the importance of firsthand observations. If home visits are not conducted, clinicians may fail to comprehend the full extent of the clutter.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria, hoarding involves a persistent difficulty discarding or parting with possessions, regardless of their actual value, due to a perceived need to save the items and to distress associated with discarding them. It often leads to an accumulation of possessions that congest and clutter living areas and substantially compromise their intended use. It causes clinically significant distress or impairment in social, occupational, or other important areas of functioning and is not attributable to another medical condition or better explained by the symptoms of another mental disorder.

Hoarding is not highly associated with eating disorders. The disorder does have a high rate of co-occurrence with depressive and anxiety disorders as well as with attention-deficit/hyperactivity disorder (ADHD). Indeed, the thought of discarding one's possessions can create intense anxiety in the hoarder. Hoarding disorder may also occur as part of obsessive-compulsive disorder (OCD), in which individuals have obsessions in relation to certain items and compulsions to collect these objects.

Hoarding can also occur as a part of organic states such as dementia, cerebrovascular accidents, or alcohol-related brain disorders. In these cases, the hoarding is relatively new in onset and much more disorganized, with more prominent squalor. As in chronic hoarding, patients typically lack insight into their disorder, making input from friends and neighbors critical to diagnosis. Medical review and examination is indicated for acute-onset cases.

The most effective treatment is CBT is typically conducted for 12 months or less.


Approach Considerations

It is important to establish a therapeutic relationship with the patient who may lack awareness of their problem or not be motivated to change their way of life.


Cognitive-Behavioral Therapy

Treatment usually involves psychological therapy in the form of cognitive-behavioral therapy (CBT) with weekly sessions over 20 to 26 weeks. [18] Often these sessions incorporate home visits with a therapist [19] combined with between-session homework. A study of persons with hoarding disorder who received 26 individual sessions of CBT, including frequent home visits, over a 7-12 month period, found adherence to homework assignments was strongly related to symptom improvement. [20


Research on online CBT sessions that give patients access to educational resources on hoarding, cognitive strategies, and a chat-group has shown promising results.

CBT, the primary form of psychological therapy for hoarding disorder, typically involves weekly sessions over 20-26 weeks. These sessions often incorporate home visits with a therapist combined with between-session homework. Home visits are particularly valuable for monitoring the patient's progress. A study of persons with hoarding disorder who received 26 individual sessions of CBT, including frequent home visits, over a 7- to 12-month period found that adherence to homework assignments was strongly related to symptom improvement. Online CBT sessions that give patients access to educational resources on hoarding, cognitive strategies, and a chat group have shown promising results.

Selective serotonin reuptake inhibitors (SSRIs) and serotonin/norepinephrine reuptake inhibitors (SNRIs) are most commonly used to treat hoarding disorder. Treatment response to pharmacotherapy is similar to the response in OCD. In addition, pharmacologic treatment of a coexisting anxiety or depressive disorder may be indicated

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Source: Psychiatry Fast Five Quiz: Test Your Knowledge of Hoarding Disorder